MEDICARE: MS. KIMBERLY ANN BLACKBURN ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT-015	OH

General Provider Information

NPI Number	:	1790748713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY ANN BLACKBURN ATC

Provider Business Mailing Address
First Line	:	11694 PROSPECT RD
Second Line	:
City	:	STRONGSVILLE
State	:	OH
Zip	:	44149-2928
Country	:	US
Telephone Number	:	440-572-0126
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 N PARK BLVD
Second Line	:	BEAUMONT SCHOOL
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-4258
Country	:	US
Telephone Number	:	440-223-3292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	09/03/2013

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